低手术量中心的大肠内镜黏膜下剥离术：香港一家地区医院的技巧与窍门以及学习曲线

Colorectal endoscopic submucosal dissection at a low-volume centre: tips and tricks, and learning curve in a district hospital in Hong Kong.

作者信息

Chong D Hm, Poon C M, Leong H T

机构信息

Department of Surgery, North District Hospital, Sheung Shui, Hong Kong.

出版信息

Hong Kong Med J. 2016 Jun;22(3):256-62. doi: 10.12809/hkmj154736. Epub 2016 May 6.

DOI:10.12809/hkmj154736

PMID:27149977

Abstract

INTRODUCTION

Colorectal endoscopic submucosal dissection is not a widely adopted procedure due to its technical difficulties. This study aimed to share the experience in setting up this novel procedure and to report the learning curve for such a procedure at a low-volume district hospital in Hong Kong.

METHODS

This case series comprised 71 colorectal endoscopic submucosal dissections that were performed by a single endoscopist without experience in gastric or colorectal endoscopic submucosal dissection. Lesion characteristics, procedure time per unit area of tumour, en-bloc resection rate, R0 resection rate, complications, and length of stay were recorded prospectively. Results were compared for two consecutive periods to study the learning curve.

RESULTS

Overall, 41 (57.7%) tumours were located in the right colon, 21 (29.6%) in the left colon, and nine (12.7%) in the rectum. The median tumour area was 4 cm(2) (range, 0.25-16 cm(2)). The median operating time was 105 (range, 47-342) minutes. The median procedure time per unit area of tumour was 24.9 min/cm(2). There was one instance of intra-operative bleeding that required conversion to laparoscopic colectomy. There was no postoperative haemorrhage. The overall perforation rate was 15.5%, in which one required conversion to laparoscopic colectomy. The overall morbidity rate was 16.9% and there was no mortality. The median hospital stay was 1 day (range, 0-11 days). The overall en-bloc resection rate and R0 resection rate was 81.2% and 58.0%, respectively. Comparison of the two study periods revealed that procedure time per unit area of tumour decreased significantly from 31.5 min/cm(2) to 21.5 min/cm(2) (P=0.032). The en-bloc resection rate improved from 78.8% to 83.3% (P=0.15). The R0 resection rate improved significantly from 39.4% to 75.0% (P<0.01).

CONCLUSION

Untutored colorectal endoscopic submucosal dissection is feasible with acceptable clinical outcomes at a low-volume district hospital in Hong Kong.

摘要

引言

由于技术难度较大，大肠内镜黏膜下剥离术尚未得到广泛应用。本研究旨在分享开展这一新技术的经验，并报告在香港一家低手术量的地区医院开展该手术的学习曲线。

方法

本病例系列包含71例大肠内镜黏膜下剥离术，均由一名无胃或大肠内镜黏膜下剥离经验的内镜医师完成。前瞻性记录病变特征、肿瘤单位面积的手术时间、整块切除率、R0切除率、并发症及住院时间。对连续两个时期的结果进行比较，以研究学习曲线。

结果

总体而言，41例（57.7%）肿瘤位于右半结肠，21例（29.6%）位于左半结肠，9例（12.7%）位于直肠。肿瘤中位面积为4 cm²（范围0.25 - 16 cm²）。中位手术时间为105分钟（范围47 - 342分钟）。肿瘤单位面积的中位手术时间为24.9分钟/cm²。有1例术中出血，需转为腹腔镜结肠切除术。无术后出血。总体穿孔率为15.5%，其中1例需转为腹腔镜结肠切除术。总体发病率为16.9%，无死亡病例。中位住院时间为1天（范围0 - 11天）。总体整块切除率和R0切除率分别为81.2%和58.0%。两个研究时期的比较显示，肿瘤单位面积的手术时间从31.5分钟/cm²显著降至21.5分钟/cm²（P = 0.032）。整块切除率从78.8%提高至83.3%（P = 0.15）。R0切除率从39.4%显著提高至75.0%（P < 0.01）。